Are medical skills lost?
Doctors considering core
psychiatric training (CPT) may be anxious that hard-won medical
skills will disappear. Whilst it may be true that, as your training
progresses, the opportunities and responsibility for practical
procedures and physical examination decrease, psychiatrists will
always be medical doctors, specialising in mental health. Medical
training instils a systematic way of approaching health problems.
This persists in psychiatry with the necessary addition of lateral
thinking and a biopsychosocial approach. Medical skills are neither
redundant nor lost in translation, but adapted and added to along
the way and it is more accurate to consider that what you lose with
the one hand, you gain with the other.
A good way of
illustrating the medical skills required in psychiatry is to
consider the senses all clinicians rely on. The
examination of the mental state calls upon you to move beyond
inspection to a more sustained observation of appearance
and behaviour. This observation includes recording visual
information such as cleanliness, dress, dentition, agitation,
distractibility, movements and mannerisms, eye contact and body
language. The discipline of recording this information develops a
skill with real clinical currency (think about someone you live
with – can you remember what they were wearing this morning?)
When listening
to the patient’s own words, take the time to record verbatim
examples. The narrative should not be discarded, as it is likely to
contain personal meaning however well hidden. Everyone has their
own communication style and psychiatrists often need to be flexible
in order to get people talking. Once you have started this process,
open questions help the individual to identify what is important to
them and closed questions can be used to define, clarify and check
your understanding. Smells reflect the life being led and
thus self-neglect, fear or the telltale presence of spent alcohol
pooling in the pores can be indicators.
All medical specialties
accord attention and value to a clinical hunch, and the equivalent
in psychiatry is probably gut feeling. However, the
decision-making process is complex, and clinical intuition (based
on the foundations of a good history and examination) should be
supplemented with collateral information, appropriate
investigations and objective clinical tools. Touch may
literally consist of a handshake but, as a doctor, being touched
emotionally (and thus left with an aftertaste) is commoner
than is admitted. Medical students asked “how did it make you
feel?” may experience initial discomfort, but the cliché has valid
and honest roots. Cultivating self-awareness and recognising the
validity of your own reactions to others contributes to successful
clinical practice. Although these skills apply to other medical
specialities, psychiatry uniquely recognises them and incorporates
training and experience in psychotherapy and a weekly hour of
consultant supervision as part of CPT. The importance of human
interactions is at the very heart of training.
Dr David Brunskill
Specialty Registrar in forensic psychiatry